Provider Demographics
NPI: | 1942780994 |
---|---|
Name: | SKYN CLINIC & APOTHECARY |
Entity Type: | Organization |
Organization Name: | SKYN CLINIC & APOTHECARY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | ZOLA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | NEMORIN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | ESTHETICIAN |
Authorized Official - Phone: | 678-447-6597 |
Mailing Address - Street 1: | 1148 WOODTRACE LN |
Mailing Address - Street 2: | |
Mailing Address - City: | AUBURN |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30011-4721 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 678-447-6597 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1150 PEACHTREE INDUSTRIAL BLVD STE 165 |
Practice Address - Street 2: | |
Practice Address - City: | SUWANEE |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30024-1903 |
Practice Address - Country: | US |
Practice Address - Phone: | 678-835-8741 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-08-20 |
Last Update Date: | 2018-08-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | ES004943 | 207N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty |